Prescriptions for Psychiatric Trouble (WSJ 19/2/10)

The proposed new edition of Diagnostic and Statistical Manual of Mental Disorders could place large swaths of the population under the umbrella of pathology.

Last week, the American Psychiatric Association unveiled the much-awaited blueprint for the next edition of its official handbook of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, or DSM V. Outlets from the New York Times to the Hindustan Times heralded its arrival. ABC News announced, “Big changes for DSM, the psychiatrists’ bible.”

Such fanfare makes sense. The DSM is as much a cultural institution as a clinical one. As an arbiter of what is normal and what is not, the manual also plays an important role in insurance and disability determinations. In the courtroom it can bear on criminal culpability.

Scores of revisions have been proposed by nearly 200 experts under the supervision of the DSM V task force, which will release a final version of DSM V in 2013—19 years after the publication of the DSM IV.

The problem is that the changes don’t really advance psychiatry. Worse, some are prescriptions for trouble. One of the most controversial is the creation of a diagnosis called “psychosis risk syndrome.” Granted, the motivation is laudable: to identify adolescents or young adults at risk for developing serious mental illnesses marked by hallucinations and delusions. What doctor wouldn’t want to intervene early to ward off an affliction like schizophrenia? But a diagnosis believed to foreshadow a full-blown psychotic illness has the potential to be highly stigmatizing. That is especially unfortunate if the labeled individual does not even go on to develop such an illness—and the chances of that are estimated at about 70%, according to a 2009 Journal of Clinical Psychiatry review paper, “Intervention in Individuals at Ultra-High Risk For Psychosis.”

To complicate matters further, treatment is not especially effective in forestalling psychotic illness in the minority destined to develop it. And since we don’t know who those people will be, otherwise healthy kids will be exposed to potent antipsychotic medications and their side effects, such as diabetes and weight gain.

Thus, until the science of prevention becomes more advanced, it is better to keep psychotic risk syndrome out of the main DSM, placing it in an Appendix for Further Research.

This is just a suggestion from one person—me. By the time the public comment period ends on April 20, the APA’s inbox will be overflowing. Indeed, within moments of the task force’s posting its draft on the Internet, psychiatry-watchers sprang into action.

Some with Asperger’s Disorder (“Aspies,” as they often call themselves) decried the proposed elimination of their category, which would be subsumed under a new diagnosis called Autism Spectrum Disorder. They resist being lumped with individuals who have lower IQs and language delays. Among the “transgendered,” one camp urged that the existing diagnosis of Gender Identity Disorder be removed because it implies they are mentally ill. The other camp wanted it left in so that insurers will pay for sex-change surgeries.

Psychiatrists weighed in, too, on various aspects of the blueprint. “The DSM V would dramatically raise the rates of mental disorder in the general population,” said Allen Frances, head of the team that revised the fourth edition of the manual. “Some of the new diagnoses would be extremely common and pharmaceutical marketing would amplify the risk of their being found. This means, of course, that a lot of otherwise normal people will be medicated.”

But the larger question raised by the proposed revisions is whether these changes help us to better understand mental disorders.

For perspective, let’s go back to 1980 when the revolutionary third edition of the handbook, the DSM III, was published. In a radical break from earlier editions, which were based largely on Freudian concepts of unconscious conflict and stunted sexual development, the DSM III categorized illnesses based on symptoms. A patient was said to have a condition if he or she had a certain number of the classic symptoms. Such an approach increased the odds that two examiners would agree on what diagnosis to assign a patient. This enabled clinicians to communicate better. Different research teams could work on new treatments for the same problems as well as compare, and confirm, one another’s work.

Yet just because two examiners concur that a person qualifies for a particular diagnosis does not mean that he has an authentic mental illness. How do we know, for example, that a person diagnosed with major depressive disorder (the formal designation for pathological depression) is not actually suffering from a bout of natural if intense sadness brought on by a shattering loss, a grave disappointment or a scathing betrayal?

The manual will not help us here. In fact, a number of changes proposed for the DSM V (e.g., new diagnoses for binge eating, hoarding and hypersexuality) are likely to inadvertently place large swaths of normal human variation under the umbrella of pathology.

The other problem that confounds psychiatry is how to draw boundaries around diagnostic categories, given that we rarely know the cause of mental illness at the neural level. Mental illnesses are the product of numerous genes that interact with one another, with the environment and also with experience. (A recent study by the National Institute of Mental Health found that 80 genes could be associated with bipolar disorder.) Add to this the miasma of social and personal encounters that impinge upon the genetically vulnerable individual—stress, poverty, family instability, drug or alcohol use, and so forth—and the causal mechanisms of any mental illness become staggeringly complex and elusive. Moreover, the “psychopathological pie,” as a colleague calls it, is rarely divided up as tidily as the manual implies. Patients often have symptoms that sprawl across several diagnostic categories. For example, half of kids who receive the diagnosis of bipolar disorder also have ADHD.

The upshot is that, with some important exceptions, drug treatment is often guided more by symptoms than by diagnosis. In fact, good psychiatrists do not rely too heavily on the DSM when they care for patients. There is simply no substitute for observing the patient, listening to his story, and fine-tuning his treatments—psychological and pharmacological—as needed.

The framers of the DSM III knew this well. They cautioned against manual users taking too literally the sharp boundaries drawn between disorders and between disorder and mental health. “This version,” they wrote in the preface, “is only one still frame in the ongoing process of attempting to better understand mental disorders.” Thirty years later, despite undeniable progress in brain science, we are saying much the same thing.

Dr. Satel, a psychiatrist, is a resident scholar at the American Enterprise Institute and a lecturer at Yale University School of Medicine.

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